Epilepsy surgery: Difference between revisions

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{{Epilepsy}}
{{Epilepsy}}
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==Surgery==
== Overview ==
Approximately 60% of all patients with [[epilepsy]] (0.4% of the population of industrialized countries) suffer from focal epilepsy syndromes. In 15 to 20% of these patients, the condition is not adequately controlled with anticonvulsive [[drugs]]. Such patients are potential candidates for surgical epilepsy treatment. Epilepsy surgery involves a neurosurgical procedure where an area of the [[brain]] involved in [[seizures]] is either resected, disconnected or stimulated.  The goal is to eliminate seizures or significantly reduce seizure burden.
[[Surgery]] is not the first-line treatment option for patients with epilepsy. [[Surgery]] is usually reserved for patients who their [[seizure]] continues to happen despite using maximum dosage of [[Anti-epileptic drugs|anti-seizure drugs]].


First line therapy for epilepsy involves treatment with antiepileptic medications. Most patients will respond to one or two different medication trials.  The goal of this treatment is the elimination of seizures, since uncontrolled seizures carry significant risks, including injury and sudden death.  However, in up to one third of patients with epilepsy, medications alone will be unable to eliminate seizures.  In these patients, epilepsy surgery is considered.
== Indication ==
[[Surgery]] is not the first-line treatment option for patients with epilepsy. [[Surgery]] is usually reserved for patients who their [[seizure]] continues to happen despite using maximum dosage of anti-seizure drugs.<ref name="pmid12528052" />


Generally, surgery is considered in patients whose seizures cannot be controlled by adequate trials of two different medications.  Epilepsy surgery has been performed for more than a century, but its use dramatically increased in the 1980s and '90s, reflecting its efficacy in selected patients.
==Surgery==
 
The goal of [[surgery]] in epilepsy can be divided into two categories:
===Surgical treatment===
* Curative
Surgical treatment can be an option for epilepsy when an underlying brain abnormality, such as a benign [[tumor]] or an area of scar tissue (e.g. [[hippocampal sclerosis]]) can be identified. The abnormality must be removable by a neurosurgeon. 
** Lesional [[resection]]
** [[Lobectomy]]
** Corticectomy
** Hemispheric disconnection
** Multiple subpial transactions
** [[Gamma knife|Gamma knife radiosurgery]]
* [[Palliative]]
** Hemispheric [[surgery]]
** Multiple subpial transections
** Disconnection procedures such as [[callosotomy]]
** Stimulation procedures including [[Vagus nerve stimulation|vagal nerve stimulation]] and [[deep brain stimulation]]<ref name="pmid12528052">{{cite journal |vauthors=McKhann GM, Bourgeois BF, Goodman RR |title=Epilepsy surgery: indications, approaches, and results |journal=Semin Neurol |volume=22 |issue=3 |pages=269–78 |date=September 2002 |pmid=12528052 |doi=10.1055/s-2002-36653 |url=}}</ref>


Surgery is usually only offered to patients when their epilepsy has not been controlled by adequate attempts with multiple medications.  Before surgery is offered, the medical team conducts many tests to assess whether removal of brain tissue will result in unacceptable problems with [[memory]], [[visual perception|vision]], [[language]] or movement, which are controlled by different parts of the [[brain]].  These tests usually include a [[neuropsychology|neuropsychological evaluation]], which sometimes includes an intracarotid sodium amobarbital test ([[Wada test]]) - although this invasive procedure is being replaced by non-invasive functional MRI in many centres.  Resective surgery, as opposed to palliative, successfully eliminates or significantly reduces seizures in about 50-90% of the patients who undergo it (the exact percentage depends on the particulars of the case and surgeon in question.)  Many patients decide not to undergo surgery owing to fear or the uncertainty of having a brain operation.
== Contraindications ==
 
[[Contraindication|Contraindications]] for [[Vagus nerve stimulation|vagal nerve stimulation]] includes:
The most common form of resective surgical treatment for epilepsy is to remove the front part of either the right or left [[temporal lobe]].  A study of 48 patients who underwent this operation, [[anterior temporal lobectomy]], between 1965 and 1974 determined the long-term success of the procedure. Of the 48 patients, 21 had had no seizures that caused loss of consciousness since the operation. Three others had been free of seizures for at least 19 years. The rest had either never been completely free of seizures or had died between the time of the surgery and commencement of the study.<ref name="Neurology2005-Kelley">{{cite journal | author=Kelley K, Theodore WH | title=Prognosis 30 years after temporal lobectomy | journal=Neurology | year=2005 | pages=1974-6 | volume=64 | issue=11 | id=PMID 15955959}}</ref>
* [[Cardiac arrhythmia|Cardiac arrhythmias]]
 
* Respiratory diseases such as [[asthma]]
[[Palliative]] surgery for epilepsy is intended to reduce the frequency or severity of seizures. Examples are [[callosotomy]] or [[commissurotomy]] to prevent seizures from generalizing (spreading to involve the entire brain), which results in a loss of consciousness. This procedure can therefore prevent injury due to the person falling to the ground after losing consciousness. It is performed only when the seizures cannot be controlled by other means. Resective surgery can be considered palliative if it is undertaken with the expectation that it will reduce but not eliminate seizures.
* [[Hoarseness]]
 
* [[Peptic ulcer|Gastric ulcers]]
[[Hemispherectomy]] is a drastic operation in which most or all of one half of the cerebral cortex is removed. It is reserved for people suffering from the most catastrophic epilepsies, such as those due to [[Rasmussen syndrome]]. If the surgery is performed on very young patients (2-5 years old), the remaining hemisphere may acquire some rudimentary motor control of the ipsilateral body; in older patients, paralysis results on the side of the body opposite to the part of the brain that was removed. Because of these and other side effects it is usually reserved for patients who have exhausted other treatment options.
* [[vasovagal syncope]]
* Previous left or bilateral cervical [[vagotomy]]  
* Progressive intracerebral disease <ref name="pmid11709642">{{cite journal |vauthors=Boon PA |title=Vagus nerve stimulation for refractory epilepsy |journal=J Clin Neurophysiol |volume=18 |issue=5 |pages=393 |date=September 2001 |pmid=11709642 |doi= |url=}}</ref>
Contraindications for [[deep brain stimulation]] includes:
* Unstable [[Heart diseases|heart disease]]
* Active [[infection]]
* Significant [[subcortical arteriosclerotic encephalopathy]]
* [[malignancy]] with markedly reduced [[life expectancy]]
* Abnormal findings on presurgical imaging (except for minor [[atrophy]])<ref name="pmid12774214">{{cite journal |vauthors=Landi A, Parolin M, Piolti R, Antonini A, Grimaldi M, Crespi M, Iurlaro S, Aliprandi A, Pezzoli G, Ferrarese C, Gaini SM |title=Deep brain stimulation for the treatment of Parkinson's disease: the experience of the Neurosurgical Department in Monza |journal=Neurol. Sci. |volume=24 Suppl 1 |issue= |pages=S43–4 |date=May 2003 |pmid=12774214 |doi=10.1007/s100720300039 |url=}}</ref><ref name="pmid16810718">{{cite journal |vauthors=Lang AE, Houeto JL, Krack P, Kubu C, Lyons KE, Moro E, Ondo W, Pahwa R, Poewe W, Tröster AI, Uitti R, Voon V |title=Deep brain stimulation: preoperative issues |journal=Mov. Disord. |volume=21 Suppl 14 |issue= |pages=S171–96 |date=June 2006 |pmid=16810718 |doi=10.1002/mds.20955 |url=}}</ref>


==References==
==References==
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Latest revision as of 21:37, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Fahimeh Shojaei, M.D.

Overview

Surgery is not the first-line treatment option for patients with epilepsy. Surgery is usually reserved for patients who their seizure continues to happen despite using maximum dosage of anti-seizure drugs.

Indication

Surgery is not the first-line treatment option for patients with epilepsy. Surgery is usually reserved for patients who their seizure continues to happen despite using maximum dosage of anti-seizure drugs.[1]

Surgery

The goal of surgery in epilepsy can be divided into two categories:

Contraindications

Contraindications for vagal nerve stimulation includes:

Contraindications for deep brain stimulation includes:

References

  1. ↑ 1.0 1.1 McKhann GM, Bourgeois BF, Goodman RR (September 2002). "Epilepsy surgery: indications, approaches, and results". Semin Neurol. 22 (3): 269–78. doi:10.1055/s-2002-36653. PMID 12528052.
  2. ↑ Boon PA (September 2001). "Vagus nerve stimulation for refractory epilepsy". J Clin Neurophysiol. 18 (5): 393. PMID 11709642.
  3. ↑ Landi A, Parolin M, Piolti R, Antonini A, Grimaldi M, Crespi M, Iurlaro S, Aliprandi A, Pezzoli G, Ferrarese C, Gaini SM (May 2003). "Deep brain stimulation for the treatment of Parkinson's disease: the experience of the Neurosurgical Department in Monza". Neurol. Sci. 24 Suppl 1: S43–4. doi:10.1007/s100720300039. PMID 12774214.
  4. ↑ Lang AE, Houeto JL, Krack P, Kubu C, Lyons KE, Moro E, Ondo W, Pahwa R, Poewe W, Tröster AI, Uitti R, Voon V (June 2006). "Deep brain stimulation: preoperative issues". Mov. Disord. 21 Suppl 14: S171–96. doi:10.1002/mds.20955. PMID 16810718.

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